Tudor Bank Limited Tudor Bank Nursing Home Inspection report 2 Beach Road Southport Merseyside PR8 2BP Tel: 01704569260 Website: www.tudorcarehomes.co.uk Date of inspection visit: 25 July 2017 Date of publication: 08 August 2017 Ratings Overall rating for this service Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led? Outstanding 1 Tudor Bank Nursing Home Inspection report 08 August 2017
Summary of findings Overall summary This unannounced inspection was conducted on 25 July 2017. Situated in Birkdale and located close to public transport links, leisure and shopping facilities, Tudor Bank Nursing Home is registered to provide accommodation for up to 46 younger and older adults who have mental health needs and require nursing or personal care. The location has a specialist unit for people living with dementia. It is a large three storey property which is fitted with a passenger lift. All the bedrooms are currently in use for single occupancy and have hand-basins. At the time of inspection 18 people were using the services for younger people with mental health conditions and 24 people were using the dementia services. A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the last inspection, the service was rated. At this inspection we found the service remained. Why the service is rated. People and their relatives told us that the service at Tudor Bank was safe. Staff were deployed in sufficient numbers to monitor people's safety. We asked people living in the home and their relatives about staffing levels. Everyone said they thought there were enough staff on duty to meet people's needs and keep them safe. We saw that staff were not rushed and were available to monitor and provide care as required. Staff were recruited in accordance with a robust procedure. We saw that people were protected from the risk of abuse or harm because staff knew people well and were vigilant in monitoring risk. Risk assessments had been regularly reviewed and changes applied where necessary. Medicines were safely managed within the service by nursing staff and in accordance with best-practice guidance for care homes. We checked the storage, administration and record-keeping for medicines and found that stock levels were correct and records were completed correctly. We noted one stock error which had been caused by a labelling mistake at the pharmacy. This was addressed immediately by staff. Safety checks had been completed as required. Safety certificates were up to date although there had been a slight delay in the gas safety check caused by a late cancellation by the contractor. This was addressed 2 Tudor Bank Nursing Home Inspection report 08 August 2017
during the inspection and no issues were identified. Staff were trained in subjects relevant to the needs of people living at Tudor Bank. This training was refreshed on a regular basis. People's capacity was assessed and consent sought in accordance with the Mental Capacity Act 2005 (MCA). This process included the use of best interest decisions for example, in relation to end of life care. People were supported to maintain a varied and healthy diet in accordance with their preferences and healthcare needs. The service operated a menu which offered good choice. We saw from care records that staff supported people to access a range of community based healthcare services on a regular basis. Some people were also supported to access specialist healthcare services where there was an identified need. Part of Tudor Bank was specifically adapted to meet the needs of people living with dementia. Adaptations and décor had been developed with the support of information from Stirling University which specialises in understanding dementia and the care of people living with the condition. Throughout the inspection we saw that staff were exceptionally caring in their approach to the provision of care. People living at Tudor Bank, their relatives and professionals were extremely complimentary about the quality of care provided and the positive impact that the service had on people's lives. The relatives that we spoke with were equally clear that they valued the staff and the quality and positive impact of the service. It was clear from observations and conversations with staff that they knew people well and understood their care needs in detail. We saw and were told about other methods of reducing anxiety and distress. Staff were able to explain that their approaches and interventions varied depending on the person and the particular situation. We saw in records and were told of numerous examples where the quality of care had a significant positive impact on people living at Tudor Bank. A professional shared information on a number of people who they had referred to the service and spoke extremely positively about the provision of care. Throughout the inspection we saw that staff spoke to people in a gentle tone and supported their communication by smiling and using other facial expressions at appropriate moments. There was gentle physical contact between staff and the people living in the home, for example, hand-holding which offered re-assurance and aided communication. We observed that people responded with warmth towards staff and that staff spoke with great compassion and care for the people living in the home. Visitors were welcome to visit at any time. Mealtimes were protected for the benefit of some people living in the home and families were encouraged to let the service know if they intended to visit during these periods. One relative told us how staff had supported them to stay and feed a family member to help them settle-in. Staff told us that relatives were often invited to stay and have a meal with their family member. For example, on Christmas Day. Tudor Bank provided exceptional end of life care and had achieved commended status within the Gold Standard Framework for end of life care. The Gold Standard Framework provides training and accreditation for care services which specialise in providing end of life care. 3 Tudor Bank Nursing Home Inspection report 08 August 2017
The majority of people living in the service were involved in the planning and review of their care. For some people this was not practical because their health condition limited their understanding of the process. Where this was the case information from relatives and staff was used to update care plans. Care records provided evidence of regular review and personalised approaches. Care records showed clear evidence of family involvement in the pre-admission assessment. We saw evidence that relatives were invited to reviews of care with the local authority. However, some family members said that they would welcome more opportunities to discuss care needs with staff. People living in the home were invited to attend weekly meetings where they could discuss matters of concern or interest. Minutes of these meetings were made available to the inspection team. The service had a complaints procedure in place which was clearly displayed. We saw that only one formal complaint had been received in 2017. This had been responded to in accordance with best-practice and the relevant policy. People living in the home, relatives and staff spoke extremely positively about the registered manager and their management of the home. Throughout the inspection the registered manager demonstrated knowledge of the people living in the home and the staff team. We saw copies of questionnaires that had been issued to people living in the home and their relatives. The questionnaires had all been issued recently and contained ratings and comments which were extremely positive and complimentary. We saw that the staff on duty during the inspection were motivated to provide a high-quality, responsive service to the people living in the home. Our observations of their practice and their responses to our questions were positive throughout the inspection. 4 Tudor Bank Nursing Home Inspection report 08 August 2017
The five questions we ask about services and what we found We always ask the following five questions of services. Is the service safe? The service remained. Is the service effective? The service remained. Is the service caring? Outstanding The service was exceptionally caring. People living at the service and their relatives spoke extremely positively about the quality of care and the positive impact that the service had on people's lives. Staff were exceptionally knowledgeable and demonstrated a caring and gentle approach throughout the inspection. We saw evidence of numerous examples where the provision of care had resulted in significant improvement in people's health and wellbeing. The service delivered accredited high-quality end of life care which reduced the risk of hospital admissions and demonstrated a commitment to maintaining people's comfort and dignity. Is the service responsive? The service remained. Is the service well-led? The service remained. 5 Tudor Bank Nursing Home Inspection report 08 August 2017
Tudor Bank Nursing Home Detailed findings Background to this inspection We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. The inspection took place on 25 July 2017 and was unannounced. The inspection team consisted of an adult social care inspector and a specialist advisor with relevant experience. Before the inspection the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and any improvements they plan to make. We checked the information that we held about the service and the service provider. This included statutory notifications sent to us by the registered manager about incidents and events that had occurred at the service. A notification is information about important events which the service is required to send to us by law. We used all of this information to plan how the inspection should be conducted. We observed care and support and spoke with people living at the home and their staff. We completed a SOFI (Short Observational Framework for Inspections) to gauge the frequency and quality of interactions with people living at the service. We observed the lunchtime experience and sampled some of the food. We also spent time looking at records, including six care records, four staff files, medication administration record (MAR) sheets, staff training plans, complaints and other records relating to the management of the service. We contacted social care professionals who had involvement with the service to ask for their views. On the day of our inspection we spoke with two people living at the home. We also spoke with eight relatives. We spoke with the registered manager, the resource manager, two nurses, two care staff and the proprietors of the service. 6 Tudor Bank Nursing Home Inspection report 08 August 2017
Is the service safe? Our findings We asked people if they felt safe living at the home. One person told us, "The staff make you feel safe." Each of the relatives that we spoke with was very complimentary regarding safety at Tudor bank. Comments included; "I've no concerns for [relative] safety", "There are no issues with safety", "[Relative] is much safer here (than previous placement). There's definitely enough staff and they keep an eye on [relative]. Staff monitor and intervene early." One relative told us about their family member and their anxieties at night. They said, "My [relative] doesn't sleep at night. The service bought a large couch so [relative] could stay with staff in the lounge." The home employed seven care staff, two nurses and an activities coordinator during the day and four carers and a nurse at night. The home also had dedicated maintenance, domestic and administration staff. We asked people living in the home and their relatives about staffing levels. Everyone said they thought there were enough staff on duty to meet people's needs and keep them safe. We saw that staff were not rushed and were available to monitor and provide care as required. Staff were recruited in accordance with a robust procedure. We saw that people were protected from the risk of abuse or harm because staff knew people well and were vigilant in monitoring risk. Risk assessments had been regularly reviewed and changes applied where necessary. Staff had been trained in adult safeguarding and knew what action to take if they suspected abuse or neglect. Each of the staff that we spoke with was clear about their responsibilities to report concerns inside and outside the service. Each person had a personal emergency evacuation plan (PEEP) which was available as part of a 'grab pack' in the event of an emergency. Medicines were safely managed within the service by nursing staff and in accordance with best-practice guidance for care homes. We checked the storage, administration and record-keeping for medicines and found that stock levels were correct and records were completed correctly. We noted one stock error which had been caused by a labelling mistake at the pharmacy. This was addressed immediately by staff. Safety checks had been completed as required. Safety certificates were up to date although there had been a slight delay in the gas safety check caused by a late cancellation by the contractor. This was addressed during the inspection and no issues were identified. 7 Tudor Bank Nursing Home Inspection report 08 August 2017
Is the service effective? Our findings Staff were trained in subjects relevant to the needs of people living at Tudor Bank. This training was refreshed on a regular basis. Staff received regular supervision from a senior colleague. The people that we spoke with were clear that staff had the right skills and experience to provide the specialist care required. One relative said, "Staff have the right skills. They're very good." While another commented, "Staff have the right skills to meet [relative] needs. [Relative] eats well and has put on weight. When [relative] got a chest infection, they were right on it." People's capacity was assessed and consent sought in accordance with the Mental Capacity Act 2005 (MCA). This process included the use of best interest decisions for example, in relation to end of life care. People who lack mental capacity to consent to arrangements for necessary care or treatment can only be deprived of their liberty when this is in their best interests and legally authorised under the MCA. The procedures for this in care homes and hospitals are called the Deprivation of Liberty Safeguards (DoLS). People were supported to maintain a varied and healthy diet in accordance with their preferences and healthcare needs. The service operated a rolling menu which offered good choice. The food that we saw and sampled was well presented and nutritionally balanced. Meals and drinks were prepared by dedicated staff and served in one of two dining rooms or in the lounge if people preferred. People's nutritional and fluid intake was monitored where there was an identified risk or health need. The service had received a rating of five out of five in the most recent food hygiene inspection. We saw from care records that staff supported people to access a range of community based healthcare services on a regular basis. Some people were also supported to access specialist healthcare services where there was an identified need. We saw evidence that important healthcare information was well documented. For example, one care record contained important information regarding swallowing difficulties. Other records contained details of contact with the person's GP, dieticians, opticians and hospitals. Part of Tudor Bank was specifically adapted to meet the needs of people living with dementia. Adaptations and décor had been developed with the support of information from Stirling University which specialises in understanding dementia and the care of people living with the condition. Examples of adaptations and décor included; plain flooring, high-contrast colour schemes, pictorial signage and brightly coloured doors. The resource manager explained that further developments were planned to ensure the service continued to meet the needs of people living with dementia. 8 Tudor Bank Nursing Home Inspection report 08 August 2017
Is the service caring? Outstanding Our findings Throughout the inspection we saw that staff were exceptionally caring in their approach to the provision of care. People living at Tudor Bank, their relatives and professionals were extremely complimentary about the quality of care provided and the positive impact that the service had on people's lives. One professional commented, "I am more than happy to give any amount of praise to management and staff of Tudor Bank. I will continue to use this service and recommend it." A person living at the service said, "Staff are very friendly and helpful. They're very nice. They're brilliant. I enjoy living here." One member of staff told us, "From admission to the home we work on getting to know the people here to help us meet their needs. We try to encourage people to be as active and engaged as possible." The relatives that we spoke with were equally clear that they valued the staff and the quality and positive impact of the service. One relative told us, "Staff are remarkable, nice, patient and gentle." While another commented, "The quality of care is absolutely unbelievable. What they've done for [relative] is amazing. You just can't fault this home." They continued by providing practical examples of the positive impact that Tudor Bank had achieved in relation to personal care, motivation and weight gain. Another relative said, "I find it very good. [Relative] seems to like staff and they like [relative]. Within 24 hours of being here there was an immediate (positive) change. Staff are always very friendly. We feel welcome." Other comments included; "We've seen such a difference since [relative] has been here. We've nothing but praise for the staff. I think they're perfect." It was clear from observations and conversations with staff that they knew people well and understood their care needs in detail. For example, we saw during the serving of lunch that staff knew which type of bread and sandwich fillings different people preferred. They checked with the chef to ensure that there were sufficient of each type and encouraged people to eat in a gentle, encouraging manner. None of the people were rushed and staff made sure that every person in the dining room was offered additional portions of sandwiches and soup. In another example, we were told about a person who experienced extreme difficulty sleeping at night and became highly anxious. Staff explained the reasons for the anxiety sensitively and in the same terms as a family member. They told us that a large sofa had been purchased specifically for the person so they could rest in the presence of the night staff who provided re-assurance when the person became distressed. The registered manager also discussed this arrangement in a subsequent conversation. This clearly demonstrated that the service was sympathetic to this person's needs and was creative in identifying a solution which enabled them to rest and receive support to alleviate their distress. We saw and were told about other methods of reducing anxiety and distress. Staff were able to explain that their approaches and interventions varied depending on the person and the particular situation. For example, we were told of some people who responded positively to a stroke of their hand, while others could be distracted before their anxiety was raised with conversations about particular subjects, music or activities. This type of intervention was recorded in care plans and we saw staff engaging and re-assuring people in accordance with their care plans throughout the inspection. None of the people living at Tudor Bank had been subject to physical restraint while living at the service and 9 Tudor Bank Nursing Home Inspection report 08 August 2017
the staff and managers prided themselves on recognising indicators of distress and intervening early. One member of staff commented, "We get to know people that well that we understand their behaviours." This meant that people were less likely to be exposed to the risk of heightened anxiety and distress. We saw in records and were told of numerous examples where the quality of care had a significant positive impact on people living at Tudor Bank. A professional shared information on a number of people who they had referred to the service. In one case a person had been admitted with complex health conditions which required 2:1 nursing. The person was described as 'virtually catatonic'. Within four months the person had improved to such an extent that they were supported to move from Tudor Bank and live independently in the community. This was attributed to 'excellent, dedicated nursing care'. In another example, a person with a particularly disruptive form of dementia was reported as settled into 'a permanent home' after three failed nursing placements. Another person was admitted to Tudor Bank with severe continence issues, no motivation to undertake personal care and sleeping 'virtually 24/7'. It was reported that within a day the person was, 'shaven, dressed and sitting in the lounge enjoying the company of residents and staff'. We saw in records that this level of improvement in the person's wellbeing had been sustained and we were told that they now regularly accessed the community with staff support. Other examples included, but were not limited to; A person who was admitted with dementia who had swallowing difficulties and isolated themselves in their bedroom. Staff engaged with specialists and supported the person to attend appointments. The person's swallowing had improved to the point where they could eat a regular diet again and they regularly participated in group activities including day trips. We saw staff support people with their personal care in a manner that was respectful and discrete. One member of staff said, "We don't shout [for assistance] when people need personal care." We saw that people who were less mobile were covered with blankets and staff checked on their well-being regularly. Staff delivered care and support with respect and explained what they were doing when supporting each person. When people refused care or failed to respond to staff, they were treated with respect. Staff took time to repeat or re-phrase questions and offered gentle encouragement as required. For example, one person declined to eat lunch before it was served. A member of staff spoke gently and discretely with them and encouraged the person to try the soup and, 'maybe a sandwich.' We saw that the person ate all of their lunch without further encouragement and had a second serving of soup. This demonstrated that staff knew how best to approach people and supported them to maintain a healthy diet. Throughout the inspection we saw that staff spoke to people in a gentle tone and supported their communication by smiling and using other facial expressions at appropriate moments. There was gentle physical contact between staff and the people living in the home, for example, hand-holding which offered re-assurance and aided communication. We observed that people responded with warmth towards staff and that staff spoke with great compassion and care for the people living in the home. When questioned and observed staff demonstrated a clear understanding of people's rights regarding privacy and dignity. They shared practical examples of how this was monitored and promoted in the provision of care. We saw that they knocked on people's doors before entering and were vigilant in the monitoring of people's personal care needs. An audit of privacy and dignity was completed by the service on a regular basis. Each person had their own bedroom that had been decorated and furnished to reflect their preferences and personality. Each bedroom was unique and homely and contained objects relating to family, hobbies and interests. Staff were able to explain how specific colours had been chosen by people and how some objects helped to calm and re-assure them. For example, one person had a series of rituals and items that provided them with re-assurance and helped to maintain their mental health. Staff were able to explain these needs in detail and monitored the presence of the items as an indicator of the person's wellbeing. 10 Tudor Bank Nursing Home Inspection report 08 August 2017
The service was particularly proud of its involvement in the Sefton Libraries' project 'Lost Voices.' The project facilitated the audio recording of people recounting their personal and professional lives for storage and access through local libraries. The project aimed to capture people's experiences for prosperity and to use as educational tools for future generations. Tudor Bank had supported four people to engage with the project and referred others who were waiting to be interviewed. The service had been thanked for their contribution after the project received national recognition. Shared spaces were bright, comfortable and welcoming. Visitors were welcome to visit at any time. Mealtimes were protected for the benefit of some people living in the home and families were encouraged to let the service know if they intended to visit during these periods. One relative told us how staff had supported them to stay and feed a family member to help them settle-in. Staff told us that relatives were often invited to stay and have a meal with their family member. For example, on Christmas Day. Lounges and bedrooms provided adequate visiting facilities which offered privacy when required. Some people went out with their visitors to access local facilities. Each of the relatives that we spoke with said how they were made to feel welcome by the staff whenever they visited. One relative commented, "Staff take an interest in residents and their families. [Registered manager] knows people and their families like they're his own. He will ring me if I haven't visited for a while to make sure I'm okay." Tudor Bank provided exceptional end of life care and had achieved commended status within the Gold Standard Framework for end of life care. The Gold Standard Framework provides training and accreditation for care services which specialise in providing end of life care. The resource manager told us, "People come here to live, not to die." They provided an example of a person who was admitted to the service with dementia, depression and a terminal illness who had no family member to represent them. The service worked with the person to develop new relationships and give them the confidence to express their wishes. The person subsequently explained that they were a Roman Catholic, a supporter of Liverpool FC and dearly wished to go to the local pub for half a pint of bitter. We saw evidence that the service had recorded each of these wishes and facilitated them. We saw a photograph of the person clearly enjoying time in a pub with a full pint of bitter. Before the person passed away, they were visited by a Catholic Priest. They were buried following a Catholic service and had 'You'll Never Walk Alone' played at their funeral. This demonstrated a genuine commitment to honour this person's wishes and provided a respectful and dignified end to their life. In another example, a person living at the service was admitted to hospital towards the end of their life. Staff worked with the person, their family and healthcare professionals to ensure that the person could return to Tudor Bank and continue to receive the care that they required. Relatives were able to stay with the person 24 hours a day until they passed away. The written feedback received from relatives following the provision of end of life care was exceptionally positive. In the three examples we saw 23 of 24 potential responses were categorised as 'Excellent' in relation to the care provided to a family member. The service was also in the process of developing the skills of its nurses so they could provide essential care and pain relief when people required end of life care. For example, staff were being trained in the administration of pain relief via a syringe-driver. This helped to ensure that people remained pain-free and that familiar staff could continue to attend to their needs as their illness progressed. It also reduced the need for people to be admitted to hospital at the end of their lives. 11 Tudor Bank Nursing Home Inspection report 08 August 2017
Is the service responsive? Our findings The majority of people living in the service were involved in the planning and review of their care. For some people this was not practical because their health condition limited their understanding of the process. Where this was the case information from relatives and staff was used to update care plans. Care records provided evidence of regular review and personalised approaches. We observed that people received care and support in their rooms, in lounges and in dedicated activities areas. People received care and support as they needed it in a non-intrusive and respectful manner. Staff were observant and responsive to people's changing needs throughout the inspection. Care records showed clear evidence of family involvement in the pre-admission assessment. We saw evidence that relatives were invited to reviews of care with the local authority. However, some family members said that they would welcome more opportunities to discuss care needs with staff. The décor, furniture and equipment in rooms was personalised. A copy of the activities programme was clearly displayed and people were also told about the alternatives for the day. We saw evidence of activities that took place in the local community and that members of the community came into the home to deliver additional activities. The service had also developed a 'dementia village' in the garden which provided further opportunities to engage people in discussions and activities. People living in the home were invited to attend weekly meetings where they could discuss matters of concern or interest. Minutes of these meetings were made available to the inspection team. The service had a complaints procedure in place which was clearly displayed. We saw that only one formal complaint had been received in 2017. This had been responded to in accordance with best-practice and the relevant policy. Each of the people we spoke with knew how to complain and said that they would speak to the registered manager if they had any concerns. One person told us, "[If I had a problem] I'd speak to [registered manager]. He'd sort it out." Relatives were invited to regular meetings where they could raise concerns. One relative said, "There's a suggestion box and we've been invited to the relatives' meetings. We would raise concerns if we had to." 12 Tudor Bank Nursing Home Inspection report 08 August 2017
Is the service well-led? Our findings People living in the home, relatives and staff spoke extremely positively about the registered manager and their management of the home. One person living in the home said, "The managers are very good. They tell you things and they're always there for you." A member of staff commented, "[Registered manager] is a very good and fair manager. The communication is good." While another told us, "It's all run well." Throughout the inspection the registered manager demonstrated knowledge of the people living in the home and the staff team. The registered manager completed a wide range of quality and safety audits on a regular basis. They understood their responsibilities with regards to the service and their registration with the Commission. Systems were in place for staff to raise concerns. These included weekly staff meetings where specific issues relating to care were discussed. Minutes of these meetings were made available to the inspection team. Staff told us that they would feel confident in raising concerns internally or reporting outside of the service if necessary. We saw copies of questionnaires that had been issued to people living in the home and their relatives. The questionnaires had all been issued recently and contained ratings and comments which were extremely positive and complimentary. We saw that the staff on duty during the inspection were motivated to provide a high-quality, responsive service to the people living in the home. Our observations of their practice and their responses to our questions were positive throughout the inspection. The registered manager provided evidence of a comprehensive system for quality assurance. The systems required regular checks of; care plans, incidents, maintenance and equipment. We saw evidence of action undertaken as a result of these audits and checks. However, the actions were not always recorded. Where minor concerns were identified during the inspection, the manager took immediate action to ensure that they were rectified. 13 Tudor Bank Nursing Home Inspection report 08 August 2017